Thank you for the feedback. I will work on providing more concise multi-sentence summaries in the future.

1. Presented by :
B.Sunil Kumar Nayak

2.  Name : ABC
 Age : 60 years
 Sex : Female
 Dept : General Medicine

3.  C/o Fever with chills since 10 days
 Dry cough since 10 days
 Breathlessness ( on & off ) since 6 days
 Burning micturation since 5 days

4.  Medical history : History DM
 Medication history : Metformin+Glimipride
 Social history : Nothing significant
 Family history : Nothing significant
 Allergies : Nil known allergies

5. S - Subjective Evidence
O - Objective Evidence
A - Assessment
P - Planning

6.  PROVISIONAL DIAGNOSIS:-
UROSEPSIS UNDER EVALUATION….?

7.  E.S.R : 60 mm / 1st hr ( 0-20 )
 W.B.C : 18,300 cells / dl ( 4k-11k)
 Hb : 10.8 g/dl ( 13-17 g/dl )
 PR : 82/min ( 72-76 )
FINAL DIAGNOSIS:-
UROSEPSIS

8.  To maintain the body temperature
 Resuscitate the patient using supportive measures to correct
the hypoxia condition.
 To eradicate the organism from the body.
 To prevent the complications associated with urosepsis.

9. S.I
NO
DRUGS
(Generic names)
DOSE ROA FRE DA DS
1 Normal saline 2 pint I.V - 1 2
2 Inj.Levofloxacin 500mg I.V B.D 1 2
3 Inj.Pantoprazole 40 mg I.V OD 1 2
4 Inj.Ondansetron 4mg I.V SOS 1 2
5 Tab.Paracetamol 650 mg P.O SOS 1 2
6 Syp.Disodium hydrogen citrate
with water
2 tbsp P.O T.I.D 1 2

10. DAYS PROGRESS
DAY
-1
O/E Patient is c/c
PR :82/min, B.P :110/70mmhg, R.S :BAE +
Lab data
Blood urea :30 mg/dl, Sr.creatinine :0.8 mg/dl, R.B.S :71 mg/dl
Na+:137 m.mol/L, K+:3.1 m.mol/L, Cl-:101 m.mol/L
C.U.E
Color:Pale yellow, R.B.C:NIL, Proteins :Trace, Pus cells : 2-4cells,
Glucose :Negative, Epithelial cells :6-8cells
Malarial parasite, Dengue, HIV Antibody, HBsAG: Negative
DAY-2 O/E: Pt is c/c, PR:76/min, BP:110/70mmhg, CVS:s1s2+, P/A:soft
LAB DATA
U.S.G Abdomen:No sonographic abnormalities were seen
Chest x Ray: No abnormalities detected

11.  Body temperature is maintained
 organism was eliminated from the body
 No other complications associated with the disease
were seen

12.  Closely monitor the vital signs like Heart rate,
Blood pressure, Respiratory rate, Urine output
and vigilance activity.

13. Drug – Drug interactions :
Levofloxacin < > ondansetron
MOA
 May causes the prolongation of QT interval may result in
ventricular arrhymias including sudden death.
Management
 Monitor the plasma levels of levofloxacin
 Advice the patient about the symptoms of this DI

14. Discharge medications:
 Tab.ofloxacin
20mg-po-bd * 10 days
 Tab.methylcobalamin
500mcg-po-od * 10 days
 Syp.disodium hydrogen citrate – 2tbsp in a glass of
water –po-tid
 Tab.rantidine
300mg-po-od * 7 days
Follow up advice :
Review after 1 week

15. 1.About Disease
2.About Medication
3.About life style modifications